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HomeMy WebLinkAbout06-06-12 (2)J 1505610105 REV-1500 Ex tnZ_ll, tFt, ~ OFFICIAL USE ONLY enns lvania PA Department of Revenue p ,.A.M Y P- n ~ .o County Code Year File Number Bureau of Individual Taxes PO BOx28o6oi INHERITANCE TAX RETURN Harrisburg, PA 1yi28-o6oi R ESIDENT DECEDENT ,~" i ~ ' ~ ~ i~~a ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 177-14-9047 10/25/2011 04/24/1917 Decedent's Last Name Suffix Decedent's First Name MI RAREFY ISAIAH B (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW OD 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust U 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number O. DALE WOLGEMUTH (717) 766-3006 First Line of Address 2510 MILL ROAD Second Line of Address City or Post Office State ZIP Code MECHANICSBURG PA 17055 REGISTEF WILLS USE ~Y ~ ~~ Z~`~ r~.S C ~^r.. r 2 r Cr ~ t Vt V ~ . i, T" `6 FILED r' U Correspondent's a-mail address: vern@vmartincpa.com TD rz :.I :^ i r`?`1 cat Ca .~ i~rnj1 `k f 7 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and c efe, Declaration of preparer other than the personal re resentative is based on all information of which preparer has any knowledge. SIGNATURE F ER ON R P IBLE F R FILIN ETURN DATE -~-ui= i" ADDRESS •,~ 2510 MILL ROAD, M~ANICSBURG, A 17055 SIGNATURE OF,PREPARE~T R THAN REPRESENTATIVE DATE,, ADDRESS 12 SUMMIT DRIV , DILLSBURG, PA 17019 PLEASE USE ORIGINAL FORM ONLY 1505610105 Side 1 1505610105 J w ~~.. 1,5056],0205 REV-1500 EX (FI) Decedent's Social Security Number decedent's Name: ISAIAH B. HARLEY 177-14-9047 RECAPITULATION 1. Real Estate (Schedule A) ........................................... .. 1. 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 24,273.79 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. 8. ( 9 ) ........................... Total Gross Assets total Lines 1 throu h 7 8. . 24,273.79 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. 16,935.87 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............. .. 10. 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. 16,935.87 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. 7,337.92 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. 7,337.92 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 6,604.13 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable 733 79 . at collateral rate X .15 18. 19. TAX DUE ....................................................... .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610205 15D561,0205 297.19 110.07 407.26 J REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: ISAIAH B. RAREFY STREET ADDRESS 561 MESSIAH VILLAGE, P. O. BOX 2015 CITY STATE ZIP MECHANICSBURG PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 407.26 2. CreditslPayments A. Prior Payments B. Discount Total Credits (A + B) (2) 0.00 3. Interest (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 407.26 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred .......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income ............................................ ^ c. retain a reversionary interest .............................................................................................................................. ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "intrust for" or payable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REVd508 EX ~ (1-9)) 7 c ,y COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF ~ /'~y,~ ~~ FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorsf hip must be(disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ., ~ ,, ~~ ~ ~ ~ ~ , -~ ~. ~- d i /.,,,,.,.. ~` ~ gyp,. .. ~~. ~,._:,, ~~~ <_ N ~, ~ . . __ 4 ~. _ . ,-~ ~_ ~~~` `0~ ~.. ~ i :Gd- i ~.. -~ ~:~: ~ ~, ~, ~; ~; TOTAL (Also enter on line 5, Recapitulation) I $ ~ ~' L", (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) ,~ ~~~i®~~iG FUNERAL EX~'ENSES & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF ~ ;~ FILE NUMBER -_ Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: (-~;,_,, ,,, c r~ ~,~ )-{ _~~.,, c ~ ~,, ~~~ : ~ ~ 1. ,. ., J~ -- ,. ..ti ~44 _., B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zip __ __ Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant __ Street Address City _ State Zip _ Relationship of Claimant to Decedent 4. Probate Fees ~ 1 '~, ~~ ~' l ~ ~~ ~, 5. Accountant's Fees 6. Tax Return Preparer's Fees ~ ~ b ;~ , w r~ ~, c ~.~ ~~ , M , ~. ~ d~ ~ Ca ~,, _ ~, ~.r., 5 ,_ / c~ ~- ~- ~ TOTAL (Also enter on line 9, Recapitulation) $ 1 to ! J ~ . (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) ~~ ~C~IE®-IULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF _ - ~, FILE NUMBER c ~., ~ <.y~ ~ ~. ~' ..~ ~ ~ , ~ _ . -~ __ r- -- - r-l - /, - l ~ ,~-~ `? RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] ~- , ,. ' .. ~.. r, -r ~~~ a ~ _ ., Q ~ r - 't - w r 1 4 ,fir `' -7 a 't r'__ ~ ~ o / I ~. ~ ~.~-> ~ t_ fir, ~ , ~~ ~ ~ ° ~ -.. ~~ i ~~ •. ~ w . ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ (If more space is needed, insert additional sheets of the same size) Premium Ylan Account Statement itwc li~ttt>; ;~ ,~ _. ~; For the period i 0/25x/2011 ~a i i /22!20 i 1 ~ __ __ -- _ 001106 _...__-____--- _.-- ~.... ~~~ ISAIAH B & DORIS B HARLEY TRT ~•••: ISAIAH 8 DORIS HARLEY TTEES URTAD 03/0'L/2000 C/0 0 DALE WOLGEMUTH 2510 MILL RD MECHANICSBURG PA 17055-5835 r 1 - L ~ L~ `~r ~~'- _;~~ It Primary account number: 50-7006-8265 Page 1 of 3 IVumber of enclosures: 0 G7~ For 24-hour banking, and transaction or ~-'interest rate information, sign on to PNC Bank Online Banking at pnc.com. '~' For customer service call 1-888-PNC-BANK Monday - Friday: 7 AM - 10 PM ET Saturday & Sunday: e AM - 5 PM ET Para servirio en espariol, 1-866-HOLA-PNC NlovingT Please contact us at 1-888-PING-BANK ~ Write to: Customer Service PO Box 609 P;ttsburj)~ PA 152300738 CJ' Visit us at pnacom TDDterminal:1-800-531-1648 For heariuK iutlr~ired clients only 1)o you re-ceive a Social Secu.tit_y or SSI check by roail'? 'I~hc 1.1.5. 'Treasury hits a ~~e~~~ rule that requires that all t~l~these benelils br paid by direct deposit by May 2013. I lore are fllree food reasons to switch to direct deposit now. lt's sale, reliable and best oTall convenient. Your money goe-s dire-ctly into your a.ccow~t, sip nc~ extra trips to the hank. Why wait until 2013. Sto~~ in a~n~~ NN(' branch or call us at 1-~Y~-7h2-22hti 7a:m-10mn, Mon-l~ri, ter dam-5rn~u Sat -Sun. l~,r mtge. inl~~rmalion on how to enroll. ~1°@rnl~llllll ~~8111 Isaiah B & Doris B Harley Ttt Isaiah & Doris Harley TTEES 1111t~rflSt t:~19C~C111g ~CCOlilit ~illlit"Iniary URTAD 03;02/2000 Account number: 50-7006-8265 Overdraft Protection has not been established for this account. ~ _, 1 ~'~'~511t Please contact us if you would like to set up this service. --~ '' Your account is currently Opted-Out of Overdraft Coverage. ~ To learn more, visit us online at pnc.com,ioverdraftsolutions E ~ ~~ f> t` ~ ~~ ~alanae Surnrnar ---~-`~` ~ ~ Beginning ` Deposits and Checks and other Ending balance other additions deductions balance `?0,52t~.Sti `_',''1`?=1.(i0 .00 `_?`?,f)~~1.4(i ___,___ balance and tees w oRt).U1 .00 Interest Summary As of 11;22, a total of $11.61 in interest was paid this year. Annual Percentage Number of days Average collected Interest Paid Yield Earned (APYE) in interest period balance for APYE this period r~.olz 2~t _'2,2t3U-ol .17 Activity ®etail ®epOSits and ether Additions There were 4 Deposits and Other Additions Date Amount Description totaling $2,424.60. 1(>;%:11 4)(ifi.'.a4 llursrl t)r•p~~sit - .AnnttU;anl PA l'reasut}' 1)cpl X\tl'~:r~\X\tfi08'~ 11!03 1,138.%(? llircet 1)c~pttstt -l'"~aor Scc _ I 'i 38.1o is •-~'`~ ~ ~ ~`L~ ~~`- t3-l S<` ~ `- US'1'reasrny 303 XXXt\t1047a Deposits and Otlier Additions continued on next page PNDMLT01-J0674257-N40-YNNNNN-002-002039 ~~ PNCBAN~ ~~x '•~'.~P C~ N SEllpj ~ 7~ ~' r«, `~~ ~1E TI~1 E '~~~E ~' EI~I~'YL~~1I~,, 1~~. ~p~,' ~ `~ , ~~G~ !100 Jonestown Road • Harrisburg, PA 17109 • 1-800-720-82'?1 • Fax 717-~41-9943 • Shawn L. Carper, Supervisor ~°ENNSyLVnN1~~ Oct 25, 2011 Mr. O. Dale Wolgemuth 2510 Mill Road 14techanicsburg, PA 17055 Isaiah B. Harley - Deceased SPECIAL CHARGES X Direct Cremation X Nationwide Guarantee Program Worldwide Travel Protection TOTAL SPECIAL CHARGES PROFESSIONAL SERVICES X Services of Funeral Director & Staff Other Preparation of the Body Facilities & Staff for Memorial Service Staff & Equipment for Memorial Service Witnessing the Cremation Private Family Viewing/Witnessing Cremation Packaging And Forwarding Cremated Remains X Personal Delivery of Cremated Remains Scattering of Cremated Remains Medical Documents/Courier Fee TOTAL PROFESSIONAL SERVICES AUTOMOTIVE EQUIPMENT X Removal Vehicle Lead Car/Clergy Car Family Car Service Vehicle TOTAL AUTOMOTIVE EQUIPMENT $1,595.00 $295.00 Included $85.00 111147 SP-5 $1,890.00 $85.00 Included $0.00 MERCHANDISE X Register Book $45.00 6% Tax $2.70 $0.00 X Memorial Cards 100 @ $70.00 6% Tax $4.20 $0.00 X Thank You Cards 2 @ $24.00 6% Tax $1.44 $0.00 X Remembrance Package $120.00 6% Tax $7.20 $127.20 Arrange For Burial X Cardboard Container X Urn Burial Vault $525.00 Veterans Flag Case Grave/Memorial Marker TOTAL MERCHANDISE CASH ADVANCED ITEMS Grave Opening Cemetery Equipment X Harrisburg Patriot News $398.85 X Souderton Independent $168.42 Vault Service Charge Clergy Church/Organist/Soloist Flowers X Crematory Charge Included X Cumberland County Coroner Fee $25.00 X 6 Certified Copies of Death Certificate $36.00 TOTAL CASH ADVANCED ITEMS SUMMARY OF CHARGES Special Charges $1,890.00 Professional Services $85.00 Automotive Equipment $0.00 Merchandise $652.20 Cash Advanced Items $628.27 St1B TOTAL $ 3, 2 5 5. 4 7 CREDITS -$1,426.20 .~~71~,"~,~ ~~(~ rr.~> AMOUNT PREPAID Date Aug 9, 1996 -$1,285.00 TOTAL $544.27 AMOUNT PAID Date Nov 2, 2011 -$544.27 BALANCE D<rTE $ 0 • 0 0 $652.20 $628.27 THIS STATEMENT MAY NOT REFLECT ALL NEWSPAPER CHARGES lu(6.~u,i lel_~ lul:i, LOCAL ~EO~STRAR'S C~~Tl~iCATiO~ O~ C~~ATH V"JARRINia: It is illegal to ciug~liLat€~ this copy E~y ~hoto~tat or° .~hotogt~a{a~:, F~c fcyr this cerlitic~UL~, `~6.UU ___P 17959710 Ccrtifiration Numbcl~ +7 rlev nrzuo6 E PRINT IN R~IANENT >~:R INN ,,,. '' ,~~~~jH t7F p~~~ \ ~ ~ ~•'`r,` _~ .. '~ .~ ~. ~• C.J .,i~ si P :[s. ~~ ©~/b ~~~~y ~9F~~hT OE~,II}~` I~lu, ce~,i?~' th;lt the infin~m.Ui~yn hcrr <~i~'rn i.~ ~I ,( ~Ltl°, ~Yic:1 Itl n: a(I rTri~~inal (u~tii~iratc (Yt llcath ;i,_ (~ I~iIL•~1 yiil~ nl( ~(~, LIx:aI Ke< (,tr:u. 1'hr (~ri~uial ~~It l~c~:(i~ r~,ll (YC i(n~~~~nrcicci t(Y the St,llc~ Vital i~.u+ rd~ ~?t~(." lur i> ~ r<Incnt filing. i.ut:(I Ill.~i~trar I)atc Is~uecl COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reversal ____ __ _ _.. ___ I Name d Decemnl (Fey, toddle, a51, sudu( 2. Sea 3 $oCW Security NumMr - _ ~ _- ~ . ... _1 Dale of Oeam (Martin, day, Year) Isaiah B. Harle Male 177 - 14 - 047 October 2 2011 5 Aga ild5l &nndayl Under I year Under I day b Date of Binn IHddn, day, year) 7 &nnplace ICey and stole or lor¢gn country, as Plata of Deam ICnec4 only awl AYnvw Oav> rows Heroes HosD~la. Otner. 94 r15 anuar i m uem ^ pa ^ ER 7 Outpalwnl ^ DOA ®Nurs~ng Home ^ Res,mnce ^DIMr ~ So+uh 30 County of Deam 9c Clly, Born. Trop dl Dealn 80. FxJrry Name (It not msututlm, glue yreel and num0er) 9 Was Decedent of H,span,c Orgrn? ®No ^ Yes 10. Race. American Nt6an. Blau. YRAe, eq Cumberland U er Allen Tw pl yes, specry Cumn, (Sp¢yyy) MQSSi Qh V a ~~ 0. (L Mea,ran,PuenoR¢an.etc) I I D¢cedem s Usual Gccu 'udn ,Mind d xuA ,vane duon most of worAl Irla Do not state reUredl White 12. Was Decedent ever .n me 13. Decedent s Educalron $penfy wiry n/gne5l grade completed) 14. Mama) Sutus: Merited, Never htaru¢d. 15 Sunning Spouse pl wire, gwe maden narwl 14nd of Wor4 Nlyd of BuSin¢55l IMuslry U.S. Armed ForreS? Elementary I Secondary (0121 College (I ~a or $.) Wdowed, Dworced (Speofy) Teacher Education ^Yes ~Nd Widowed Id Dec¢deMS Malluly Address lSUeel uty. sown, stale, np cdd¢I Decedent's Drd Decedent 561 Messiah Village P O Box 2015 A"oalResdent¢ nor gale Pennsy „G ®y¢,,p¢t,den,Lnedm Upper Allen lvania ow~ rwD , . . no cd„nn Cumb w d 1°^NO,oateaentD°edw'm" l Mechanicsbur PA 17055 . er an Aclud Llmllsa crryrBord 16. Famar's Name (First rn,d3e, last, suHu( 19. Homer i Name (Frst, rnldaa, rnaden surnalili( Isaiah B. Harle da ockart 20a. Inlormanl's Nome (Type; PrrnO 200. Inlormanfs Mading Aodress (Street. ury I town, zUle. zp code) Mr. 0. Dale Wol emuth ill pad echanicsbur 17 21 a Memud of D,Sposlraan ®Crernauw, ^ 0«a4on 2 f o Date dl Dispow4on (HOnln, mY. year( 21c. Place cl Dlspo4uon {Name of certwlery. wemalory «omer pace) 210. LGC¢Ia/, (c,ty I town, sine, [p cOdal ^ Buna ^ Removal Iron Salle j Wy Cremalgn a DorrOOn AuUsorWd ^ olne sPauro ; nyYedkalEAAmrnerlcaonerT ~res^Nd October 27 , 2011 Cremation Societ of PA Harrisbur PA 17109 nor Sprat aFanerYSence ~ rear s,xn( 22D.LicenseNwrlmr ncNameandAd aessaFatany Auer Cremation Services of Penns lvania Inc ~ l FD-138753 y . 4100 Jonestown Road, Harrisbur PA 17109 23at ody wnen cendyug 23a To me msl d my 4nowkage, OeaU otcurted at IM Unw, dale ar4 place sated. IS~gnagre aM em) 230. License Number 27c. Date Signed (MOnU. my, year) plySeJan Is nd dvaYWW al Ixne d Deam 10 randy Cawyl d main. IYrru 21-20 msl m canGreted Oy per5un 2a. T re of Deam 2S. Date Prwwaced Dead (Hoorn, day, year) 26. Was Case Relerre0 ro MediW Eaaminar, Cwawr to a Reason Omer roan Cremaoun « Dauuon? win w«ro,atcas mum. O 5 ~ q $ M. vL~ 5 1') I ^ Yes ~] No CAUSE OF DEATH (See ina4sscUonA and eaamplas) , Apprdunate mtanal. Pan Ir. Emer ouwr y«ul ~ podia,,.. ins ~r,..eu,a~ ?9. Oa tooacco use C«wa,re a Deam? em Z] Pan I: Ema• IM [Nin of events - d,seases. inWrrc. w c«relicarwe - mal6•x4y caused me beam. W NOT enter lerenuW evens sutlr as wdac lesgragry attest, a uenmruWt f10tWa4on wlVqul SMnng ale e00bgy. lul aJY ale CauSd a1 eadl One a"acr. , Onset to Deam I WI n« rasulrarg ,n me urgeMrng ~uaa gran m PM I. ^ Vas ^ PraDaay . IYYEDUITE CAUSE IIfinal msease a ~ ^ No ~lAaurown arrOHlon lesd4ng In OeaU( _~ ) a G~r,cy~G ~. orr~re>hv ~ h ~r~~f ~ayle ~ e ~ i ~~,~ y~~c~C~rh~~ ~ /hWc~~l 29 H F ~(e~,,w, Due to (or az a cnrtsequer>ce o $aguara4y 4sl [adiWns,AeM, b Ieadp to ale fduyl 45IW Orl One a ~ I ~/7} / /y ~G(,J (.~iI CLY f'f"~~~!/Ifi [ly~eP ~ C-I ""' Dre9"anl wohn bast Yea ^ Preryw4armedmam . Due m (« az a coM1Seguellce o '. Emer Ow UNDERLYWG CAUSE O ~ ^ Not DregwM, Ga prequre wan a2 daYs e°~15° «n,wy UBI nnMled tin c. u resumng n deem) UST. r ~{7 I/YN yG ~LIC~I")E C1~12'x d mum Due ro (or az a consequence oft ^ Nd gequM, bl pregrurN 1~ days q I year d //,, _ // ,,,, ((,, ( fYlf~2Q!rf Q/ K ~ C~~LQ~ mlae mum 1 / ^ Unerown ~l pegwu resit m¢ pay Year 30a. Was an Aulupsy 300. 'Nara AulopSy Findings 31 Ma d Deam 32a. Dula a InWry (HOnm, mY. Yea) 320. Descrde How Inryry Occurred 72c Place d InWry Mato Fain 9rsN. Fatlory. Penwmed? Avagde Prix q Carpla4m ' Nalwal ^ Homlcbe OIOCe B,Wmg, etc. (Speahl a Cause d Deam + ^ res ^ Ves ~ ^ Acadent ^ Pendng Inveslga4on 320. Time pl InWry 72e. InW ry el Work? J21. II Transpoml,m InW7 (SpeoA'1 72g. Catalan d InWry l5treer, aly r town, stale) ^ Suede ^ Couq Nol m D¢IerrfuMd ^ Yes ^ No ^ Dover; Operalw ^ Passenger ^Pedeswn M Joiner ~ Speory J7a Cendwr (unec4 a,ly «,¢, 3 Sgnawre and Tole a Cem4er • Cer0yin9 DOY+~ IPnyycan cerulymg cause d aeatn wnen anaMr pnYS¢lan has Drpraunced darn aM Wnrplered Item 271 ,/ ~, ~ ~ ~~ To 1M Oeal of my 4norlMge, malA acsured dra Io tM cause(s) and manner u staled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~ .~ (/~~' '~^' "'" _ • Pronoumm~g are arulyrng pnyaiclan (PnysKan pan goraurcl~ry mum and cerutylrg to rouse d men( 73c Lcense NurnOer 770 Date 5 ~~ IMOIIm, mY yawl ''~ J Td IM Deal d my 4110wledge, main octurfad al IM Ilme, mU, and pYa, arsd dw td Vw da..vae) and mNMr az atale~ _ _ _ _ _ _ _ _ _ _ _ ^ • Yedka Examiner l Coroner _ _ _ _ _ _ _ ^ „ n ~ 1 S ~(~ ~ / ~ y ~ ~ ~ ~ / / / Dn Uro Ww of esaminalian and / or inveeligatian, in my dpiaon, maU occurred at tM lime, data, and prate, and due to IM cause(s) +nd manner a roted_ ^ 74 Name a nor Address of Perspn Writ Competeo Cause of Deam loam 271 Type: Prat ~ ,~r, 75 ar55,ynatpr iyryjN ,r ¢r a 3 a a- I I I I I~ 3a Da F ~ Morlm y,aar, % 5f7 rZr~ H N'O~r~ ~3Fr~c-sN rc< i~ , ~C ~f~rth-7~;cs:~~i~G P~~ 2 ' ~ c / ~' L .~.,_ / ~ tcE.t, ~ vU b ~7. i~-os~ Drspovrbn Perm,t rro. 06 918 8 8 COMMON'WEALTI3 Ol+ PUNNSYLVANIA SI-ICIRT CI:RTII+ICATE COUNTY OF CUMI3LRLANU ° . ~:., ~3) r;' a ,' '., ~~ u. 1, Glenda Earner Strasbaugh, Register for the Probate of Wills and Granting of Letters of Administration in and for Cumberland County, do hereby certify that on the 22nd day of December, 201 1, LETTERS TESTAMENTARY in commun form were granted by the Register of said County, on the estate of lsaiall I3. I-Iarley ,late of Upper Allen Township in said county, deceased to Dale Wolgemuth O. Dale Wot~emuth and that same has not since been revolted. IN TESTIMONY WHEREOF,1 have hereunto set my hand and affixed the seal of said office at CARLISLI~~, Pennsylvania, this 12th day of December, 201 I. Date of Death: October 25th. 2011 Social Security No. 177-1 ~-9047 Estate No. 21-11-1327 Deputy NOT VALIU WITIIOU'1' ORCINAL SIGNA'1'UR~, ANll 1MPItLSSCll SLAL Tlae Isaiah Buckzvalter Harlev Pour Over )%Vill LAST W1LL AND TESTAMENT (Pore-Ove~~ tiVill) Of Isaiah Bucl~walter Harley I, ISAIAH BUCI~VVALTER HARLTJY, a resident of the City of Mechanicsburg, County of Cumberland, Commonwealth of Pennsylvania, which I declare to be my domicile, do hereby make, publish, and declare this to be my LAST WILL AND TESTAMENT, hereby revoking all Wills and Codicils at any time heretofore made by me. FIRST: Declaration Concerning Family. I declare that I am married and that my wife's name is Doris Brehm Harley. I have two (2) children, namely: Cheryl Saylor and Michael D. Harley. SECOND: Nomination and Appointment of Executor. I hereby nominate and appoint Doris Brehm Harley to be my Executor hereunder, to serve without bond. In the event my nominee fails to become or at any time ceases to be the duly appointed and acting Executor hereunder, I nominate Cheryl Saylor as Executor, to serve without bond. In the event my nominee Cheryl Saylor fails to become or at any time ceases to be the duly _ ,~~,_,;4 .;~~~ appointed and acting Executor hereunder, Inominate- l~las Executor, to ,~ ~ ~- ~ ~ ~~ serve without bond. The term "Executor" as used herein hall a l~ re ardless of ender ~.. -~~' ~'t~'=~~;~~~ pp y ~ _ ._ g ~ ,~~,. , .. ~~~.~ (.i,~t~'.trf,i~.`;,~~- ~.~.:~-/<'°' /1'/ic{1rte I /J /fi~(e,~ `~f 1_~<</ ~ C-/o(c~ ~>`~,t~~%li-`- _ ~~,1-~~' 1' ' ~~" .~~ THIRD: Debts, Taxes and Administration Expenses; Powers of Executor. I ha ~i<u~L~''~~ provided the payment of all of my debts, expenses of administration of property wherever'~~ 1 y, ~~~-i situated passing under the Last Will and Testament or otherwise, and estate, inheritance, transfer, and succession taxes, other than any tax' on ageneration-skipping transfer that is not a liability of my Estate (including interest and penalties, if any} that become due by reason of my death, under The Isaiah Buckwalter Harley and Doris Brehm Harley Revocable Living Tnist, signed earlier this day and bearing -the same date as this Last Will and Testament,, (The "Revocable Trust"j or if my wife predeceases me, under the TRUST A created by said Revocable Trust.. If the Revocable Trust assets should be insufficient for these purposes, my Executor shall pay any unpaid items from the residue of my Estate passing under this Last Will and Testament, without apportionment or reimbursement. In the alternative, my Executor may demand in writing, addressed to the Tnastee of the Tnist, an amount necessary to pay all or part of these items, plus claims, Tlae Last i~~ill and Testaaraent of Isaia/a Buclcwaltea• Harney The Isaiah I3ucl~tivalter Ha~-lev Po~i~r~ Over T~Vill pecuniary legacies, and family allowances by court order. I authorize my Executor to receive and retain any of my property; to sell at public or private sale, encumber or lease any property of my estate without notice, at such prices and upon such terms as he/she deems best, and without the giving of any bond, subject, however, to such confirmation as may be required by law; to hold, manage and operate such property; to continue the operation of any business of my estate, alone or in partnership with others, for such times and in such mamler as deemed advisable, or to sell or liquidate such business, and any such operation, sale or liquidation shall be at risk of my estate and without liability on my Executor for any losses resulting therefrom; to invest and reinvest surplus moneys in such investments as he/she deems advisable; to determine what is principal and what is income of my estate and to allocate and charge to either principal or income any debts, taxes and expenses of administration. FOURTH: Disposition of All Property, Exercise of Power of Appointment. It is my intention by this Last Will and Testament to dispose of my separate property, if any, and also my share of the held propei-fy of my wife, Doris Brehm Harley, and myself. I do not intend hereby to exercise any power of appointment which I may have arising from that Trust Agreement described in Paragraph SIXTH. FIFTH: Disposition of Personal Effects. Except as provided in any written instructions to my Executor regarding the disposition of personal effects, I give any interest I have in all personal automobiles, clothing, jewelry, china, silver, books, pictures, and other works of art, household furniture and furnishings and all other items of domestic, household or personal use to wife, if she survives me. If my wife fails to survive me, I give such property to the Trustee of that Trust Agreement described in paragraph SIXTH. The bequests made by this paragraph shall be free and clear of estate and inheritance taxes, which I direct my Executor to charge against the residue of my estate. SIXTH: Disposition of Residue of Estate. 1. All the rest, residue and remainder of my estate, both real and personal and of whatever kind and wherever situated, including all of my separate property, if any, and my share of the jointly held property of my wife and myself, I give, devise and bequeath to the individual or bank then acting as Tnistee under the certain Trust Agreement designated as The Isaiah Buckwalter Harley and Doris Brehm 1-larley Revocable Living Trust, signed earlier this day and bearuig the same date as this Last Will and Testament, of which my wife and I are Co-Trustors and Co-Trustees, to be combined with the other assets of the tntst and held, administered and distributed ~as a part of that trust, according to the teams thereof and any amendments invade to it prior to my death. It is my intent, if it be permissible, not to create a separate trust by this Last Will and Testament and not to subject, The Isaiah Buckwalter Harley and Doris Brehm Harley Revocable Living Trust, or property added to it by this Subparagraph (I) to the jurisdiction of probate court. Should I be the Surviving Spouse, as defined by such Agreement, the distributions under this Paragraph SIXTI-I shall be to TRUST A only. The Lest YVill ar~d Testament of Isaiah BT.rckwalter Harlev The Isaiah Buckwcaltej~ Hardev Pour Over- Will 2. If for any reason the disposition of Subparagraph (1) is not operative or is invalid, or if the trust referred to in Subparagraph (1) fails or has been revoked, the I give the rest, residue and remainder of my estate, including my share of the jointly held property, to the individual(s) or bank which would have been Trustee of such bust had such trust been operative, valid and unrevoked at the time of my death, to be held, administered and distributed under the terms and conditions of The Isaiah Buckwalter Harley and Doris Brelun Harley Revocable Living Trust, signed earlier this day and bearing the same date as this Last Will and Testament, which trust is incorporated herein by reference. 3. Anything else herein to the contrary notwithstanding, should any portion of such trust be terminable upon my death, the disposition made in this paragraph SIXTH shall be made directly to the beneficiaries for whom the outright disposition from the trust shall be made, and the remainder which will remain in such tr1-st, if any, shall pass into such trust under the provisions of Paragraph SIXTH (1) or (2), as the case maybe. 4. Should the Trustee of that Tnist described in Paragraph SIXTH (1) or (2) elect not to pay any or all of the estate, gift or inheritance taxes from such trust, then, to the extent they are-not so paid, all taxes levied by the United States or any state, district, territory or possession thereof upon or because of any property passing under this Last Will and Testament or any Codicil thereto or by reason of any transfer or gift made by me during my lifetime or at my death, or which may be imposed by reason of my death, or the acquisition of property of any person upon my death by succession, inheritance, survivorship or otherwise, shall be paid out of the residue of my estate as an expense of administration. My Executor is authorized to accept any distributions from the Trustee of that trust described in Paragraph SIXTH (I) or (2) for proposes of such payment. SEVENTH: Omitted Heirs; Wi11 Contests, Except as otherwise specified in this Will. I have intentionally and with full knowledge omitted to provide for my heirs at the time of my death. If any beneficiary under this Will attach any of its provisions or the trust described in Paragraph SIXTH herein, directly or indirectly, any share or interest in my estate given to such person under this Will is hereby revol.ed, and such share or interest shall be distributed in the same manner provided herein as if such person had predeceased me. EIGHTH: Partial Invalidity. Should any part, clause, provision or condition of this Will be held to be void, invalid or inoperative, then I direct that such invalidity shall not affect any other provision hereof, which shall be effective as though such invalid provisions had not been made. " IN WITNESS WHEREOF, I have signed and subscribed my name to this Will this ~. -~ ::) ~,~~~:' day of I'' c~ r ~;:_ 1,~. , 200 ~',~~ Isaiah Buckwalter Harley The Last Will and Testament of Isaiah Br~ch-tr~alter Ha~~ley The. Isaiah Biael~walter Harley Pour Over Till ---> The foregoing instrument, consisting of this and ~~ -~_'~~?) preceding typewritten pages was signed; sealed, published and declared by Isaiah Buclcwalter Harley,-the Testator, as and for his Last_Will and Testament in his presence and in the presence of each of us and all of us together; and the Testator, upon declaring this document to be his Last Will -and Testament, requested each of us to sign the same as attesting witnesses; and we thereupon signed our names hereto as such witnesses, in the presence of the Testator, and in the presence of each other, on this`.-~,~~' day of ~~'` ci~~, ~ ~~, 200% . We further state that each of us believes that, at the time he executed the foregoing inshlunent, the Testator was of sound mind and memory, of lawful age, and did so execute it as his own free act and deed and not under the unlawful influence of any person. ~~°~-L-~e ~~ C~,,~..~._. residing ~'J.~ec d~ 4 ,~~ti~~~-. ~ at ~ ? ~ s'-.~ :~ ~,..:~, ,~~~~ l;~_•Lv reSldln '~ 'C? ~~. ~~, ~~_a .:.__ .-- ,~ ~ 3 The Last >=Vill and Testament of Isaiah Bucklvalter Har-lev The Lsaiah Buclcwcrlter Harley Pour Over' Will AFFIDAVIT OF ATTESTING 'WITNESSES COTV~MONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND Isaiah Buckwalter Harley, ~ ! ~~ l-v~~' ~ ~ . ~ ~~ i F_~'~~~_ and - ~! ~~ E~~ ~~-. ~~ .1-'1/~ f (~; the Testator and the Witnesses whose names are signed to the attached or fore~;~ing instrument, being duly qualified according to la~v, depose and say: (1) That they are, respectively, the Testator and the Witnesses whose signatures appear on the attached or foregoing Last Will and Testament; (2) That, on ~~~_r_:;t~ ~;; ;~=~;,~,;•~'~`, 200 ~~=~ , in the presence of each of the undersigned Witnesses, Isaiah Buckwalter lIarley, signed and executed his name to the attached or foregoing Last Will and Testament at the end thereof and each of the undersigned Witnesses saw the Testator sign and execute the Last Will and Testament; (3) That, at the time he signed and executed the Last Will and Testament, the Testator declared the instnmlent so signed and executed by him to be his Last Will and Testament; (4) That the Testator signed willingly and executed the Last Will and Testament as his free and voluntary act for the purposes therein expressed; (~) That each of the undersigned subscribing Witnesses, at the request of the Testator, and in his sight and presence and hearing, and in the sight and presence and hearing of each other, thereupon signed as a Witness thereto; (6) That the Testator, at the time of the execution cf the Last Will and Testament, was at least eighteen (l8) years of age; (7) That, in the opinion of each of the undersigned Witnesses, the Testator was, at the time he signed the Last Will and Testament, of sound mind, memory and understanding; (8) That, in the opinion of each of the undersig~t~ed Witnesses, the Testator was, at the time he signed the Last Will and Testament, under i1o constraint or undue influence and not in any respect incompetent to make a Last Will and Testament; language; (9) That the Testator could read, write and converse in the English Last l%Yill and Testament of Isaiah Buclctvalter Harley ~~,~ ~, Testator Initials ~ ~ /-~ Witness Initials ~1 ~~ , ~ The Isaiah 13i[ckZValter Harley Pour Over GVill (10) That the Testator was not suffering from any defect of sight, hearing or speech or from any physical or mental impairment which would affect his capacity to make a valid Last Will and Testament; (11) That the Testator signed only one copy of the Last Will and Testament on such occasion. (12) That each of the undersigned Witnesses was acquainted with the Testator or examined proof of Testator's identity at the time the Last Will and Testament was witnessed. ~~~ ~a~~~~~~ Testator / ~~~~, Witness ~` -,._ Subscribed, sworn and aclaiowledged before me by Isaiah Buckwalter I-Iarley, the Testator, and by ~ I ,~• ~ • . !, ._' ~ - , ~ GJ'o~~ ~~,_ ~ k 1 ~ Fy, and _, R,~w~j,~ f=", ~.,+~~- ~., W1tneSSeS t111S ~~' •~~~~ day of i``1~,,~r ~., 00 ~~.--~-'-~ , 2 l %~ i~ ~,~ .,~_- ~~.~ i f Notary Publie` ! My Commission Expires: ; ~ ~~~ ~;~~;,~~~~, _____~ ._._~_-__ _._._a nJ~,.~r~~~J s~~~! G1ertR.Vda~~tje,lr. h.i~tiaryJ'u!:~lir, f~JoriJi ~a~eii2lir~;:; AI!~tfic?r!t+ C;:i!riiy J iVy C:ot;,mi~~sion E;::~ires r~1o~i. 10, X003 P,~~mber, Panns~.jlvania : ,., ;ori^~iicn; of ~;~}t~ri~°;: Last tiVill and Testament of Isaiay~ 13uch-walter Harley r ---~~ Testator Initials~~ Witness Initials ~~~~ ~~ ~'~ ~-~~~ The Harley Farnily Arste~~~drrtents to Trust AIVIENI)M~1`~TS TO Tli~ Isaiah Buckwalter Harley and lloris Brehm Harley Revocable Living Trust - .j Isaiah Buckwalter I~:Iarley and Doris Brehm Harley; Co-Tnlstors: Executed a Trust Agreement dated _ rf ~~~..-f. L~ ~ ? , 200 ~a , Establishing T'he Isaiah Buckwalter Harley and Doris Brelun Harley Revocable Living Trust. Pursuant to the powers granted in ARTICLE .~_~.w v~'"~ of the Trust Agreement, Co- Tnlstors have the power to amend the 1 rust Agreement by written instrument signed by both Isaiah Buckwalter Harley and Doris Brehm Harley, Co=Tntst~rs and filed with the Tni~tee Co-Trustors desire to amend. *~ _- which shall be effective as ~~ ' `~" AKTICLE ~~~ ~ _~_ ~ <~ ~ is hereby amended to read as f ,. < -~ _~ ~ x,41, . ~ . t -.~ i 1 I ,.~ i f ` ~:.;~ Lt~ Jla h- wind amendment, .~. ~ ~ , -~, ~~ ~~. i_. ~ W " ~ ~ ~ t Z` .4 ~~ ~ t ~ ~ ;~~ ~ ~ ~ ~ { 6 _,. ~ 1. .~~'~ ~ + ! (l ~i { IN WITNESS WHEREO.h, we h~, ~ ; :=--w' __.,~~ument to T,.,._ ,~;,r,-~-~ s :, 200 r ,f r ._.}~ ' , , 1 ~ ~~.~~ ~ is J ~~ 1.L ,~~ ~ / r ~ , y ~ ~1, '. lX ~ L- //~ t Isaiali Buckwalter Harl ~~ ~,,u.--_=-~ ~~~~ j ,;, ,,r .. ~~,_, ~~ Doris ~3relrrn I~ar•Iey %~-v ` " s; ,~ ~..~ _ ~_, _ 7 .. R .. f ~, ,. -~% ~- . E.~<~: ~~, ~;, ,; ~ ~ ~~~ {; 1..~. ~^'. i ~ _. ~ i Amendments to Trr _ _ Tl(e Flcrrley Family flrriend~raerats to Tr•i~st AIi~IEND1VtENTS TO The Isaiah Buclwalter ~-Iarley and Doris Brehm Iarley 12evocable Living Trtyst ..f t Isaiah Buckwalter Harley and Doris Brehm I-Iarley, Co-Trustors: :Executed a Trust Agreement dated ;~~rzt.,-c:. ter. `_> 200 C= Establishing The Isaiah Buckwalter Harley and Doris Brehm Harley Revocable Living Trust. Pursuant to the powers granted in ARTICLI/ ._~-..~~~~ ~'~~~ of the Trust Agreement, Co- Trustors have the power to amend the Trust Agreement by written instnunent signed by both Isaiah Buckwalter Marley and Doris Brehm Harley, Co-Trustors and fled with the Tr~~istee. Co-Trustors desire to amend the Tnist Agreement and make the followin amendment, which shall be effective as of the date of execution hereof: ~r~..-g~? t..~~~;'~-~", _ ____, ARTICLE ~ ~ s' 1 ( r~ <'_ ~--~~~~~ <~ ,:~ ~" ,~ _) is hereby amended to read. as follows: r ~~-~-- \ao _ c r1 .r. r ,: E ` r= 1. ~ 1"~ ~ t ~ J .._ r ~ ' 1 ~ ~J l L1 i < . i ... h n ~/,. C _ t 11 I - ~ . ..., . ~.~Q_i' Y \ yw. S' n r ``)) yl~ I . ~/ ~7 1 ~{ /1' / f i]rt~ l {Y~.~ f { ~..i Yv-_V~~; , Y ( ~~.~~~ 11 \ (~1 7 ~~ \ ~ ~ f _ .- I ' f 1 r ~ ... ~ i I ~ i ~, ~ ~ J~..~, / )_ L^ / ~ l r• r C .L< c:. 1,,'~_ ~ __t5 ~._ b c': r- f _ _,. ., ~, ~ ~ l1 ~ Lit r ~-~:'"~_ ~ ~~' ~ J . _ -.~_ ~'~I',.,.. i ~..~.. '. IN WITNESS WHEREOF, we have signed this Amencirnent to Tnist Agreement this ~, l "r?_~r` L. day of ~-~~_ ~~ r t~ r,~r._~ , 200 ` ~ lsaiah Buckwalter Ilarleiy ~ ~...._._ - .,, w, ,-~ ~, - ° - ~ ,~~.~ Doris Brehm Harley Amendments to Tn~st w 00 ~ ° N O ' OOFN •Z .~ ¢xnoo 0 .a~_ ~ ~o cn z zQ o o n M ~ U r w ~^ ] O F W O NO N O /`~.~\y^1 Iw. ~ ~' J 2 Q ` V ^~ V l ~ ,~ ~ ~ ~~ ~ ~ ~ I~ ~ ~ v ~ _i ~~3